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Tuesday, October 23, 2012

What do respiratory therapists do?

Respiratory Therapists (RTs) are professionals who work alongside nurses and doctors in caring for patients. The scope of patients we treat, and the scope of what we do, is almost too great to expound upon in one simple blog post, although I'm going to try here.

This profession started in the 1940s when taking care of oxygen equipment became too much work for nurses. The profession of inhalation therapy was slowly taking hold. Most of the first inhalation therapists were nursing assistants (mainly men) who's job it was to haul tanks into patient's rooms. In essence, they were oxygen jockeys.

In the 1950s oxygen was piped into patient rooms, and the need for oxygen jockeys was slowly eliminated. Yet also in this decade aerosolized medicine therapy was revolutionized. In 1952 the first metered dose inhalers hit the market. It was also in this decade that the first effective and marketable glass nebulizers hit the market. So now the task of RT shifted from oxygen jockeys to nebulizer jockeys.

The medicine aerosilized in nebulizers in the 1950s was epinephrine and isoproteronol, with the later being a refined version of epinepherine. These were medicines that relaxed muscles wrapping around the air passages of the lungs, and thus made breathing instantly easier for asthmatic and chronic bronchitis patients. It was our job to give this medicine, and to assess the patient before and after treatments.

Since then most aerosolized has been refined so much that it works better and side effects are negligible. Because of this it is prescribed by doctors for pretty much any patient with a breathing problem or with a wheeze. So being a neb jockey remains to this day part of the RT profession.

Some hospitals allow RTs flexibility in determining who gets aerosols by means of protocols, although some hospitals don't have protocols. So the degree that an RT is allowed to use skills learned at school and through experience differs from one institution to the next.

Another thing that happened in the 1950s that greatly influenced the RT profession was the polio epidemic. Some patients with polio became so weak they couldn't breathe and required artificial respirations in order to stay alive. This was a time when the iron lung became popular in hospitals. These were large, bulky machines that were a lot of work for nurses. So managing them became the job of inhalation therapists.

In the 1960s the name was slowly morphed into respiratory therapy. Likewise, the iron lung was phased out in favor of smaller and yet more complex positive pressure ventilators. To run these machines required a lot of math and science and common sense. To benefit the patient RTs and doctors had to participate in critical thinking.

One of the main problems with this profession was that while nursing was recognized by the government, respiratory was not. So in order to improve respect for this profession the National Board of Respiratory Care was created to improve education for RTs and to create tests that must be passed in order to become a certified or registered respiratory therapist.

Originally these tests were oral and, so I'm told, quite challenging. The reason for this was because the NBRC wanted to make sure all RTs were well rounded critical thinkers as well as people who could perform a task. RTs were now trained perhaps even more than doctors on how to manage the airway, and would be assistants to physicians more so than just jockeys who do tasks.

So as you can see, this profession is still growing. There are many tasks we do, which include:

Electgrocardiograms (EKGs): This is a quick five minute test where the RT (or EKG tech) hooks the patient up to a machine that records the electrical activity of the heart. It's a great test to see if there is any abnormality. It's a great tool to help doctors assess and treat patients.

Stress Testing: This is an outpatient procedure whereby the patient runs on a treadmill and their heart is stressed. A rhythm strip of the heart and blood pressure is monitored by the RT and physician to determine if the heart is healthy. Depending the specific test ordered, the procedure can last anywhere from 30 minutes to an hour and a half.

Breathing treatments: You put liquid medicine into a nebulizer cup and the patient inhales the mist created. A typical treatment lasts 5-10 minutes. The majority of these treatments are given to asthmatic and chronic bronchitis patients who have breathing trouble.

Assessing patients: This is generally done before, during and after breathing treatments. If a patient is having trouble we are one of the first called to the scene to provide our excellent lung assessing skills.

Oxygen therapy: This involves deciding who needs supplemental oxygen, setting it up, and monitoring it. There is a variety of equipment available to help patients get oxygen from the simple nasal cannula to big equipment such as ventilators.

Pulmonary function tests (PFTs): This is a series of breathing tests to help a doctor diagnose lung diseases.

Arterial Blood Gases (ABGs): This is an invasive blood draw. Yes, you get to draw blood to. This is where you draw blood from the artery (usually from the wrist area). The blood is tested to see oxygen, CO2, and bicarb levels. The results may help you and the doctor decide how much oxygen to give patients, and whether they need (and how much) assistance with their breathing.

Suctioning: Some patients have trouble bringing up secretions and need our assistance. This is kind of like when you go to the dentist and they suck spit from your mouth, only we often go a little deeper. It's an invasive procedure, and it's often rewarding for us when we can make something complex an uncomfortable for the patient as easy as possible.

Managing the airway: We pretty much do anything that has to do with the airway. We suction, we use an array of equipment and machines to breathe for some patients, we do breathing treatments, we clean and suction tracheotomies.

Intubating and/or assisting with intubating: When a patient is having trouble breathing, or when he stops breathing, we often insert a tube through their vocal cords and into their lungs. This way we can breathe for them using Ambu-Bags and ventilators.

Setting up Ventilators: Once a patient is intubated we have to determine what ventilator to use and then we must set it up. You and the doctor must use your experience to determine what buttons to push and where to set them at to benefit the patient.

Managing Ventilators: This is where your math and science come into play. You use your education and skills to determine what settings are best for the patient and then you titrate these settings until the patient is ready to be extubated (take the tube out of his lungs). Here you'll need to use your critical thinking skills (see below).

Protocols: These are policies that allow the RT to use his skills to determine at the bedside what is best for the patient. You'll need to use your assessment and critical thinking skills.

Critical Thinking: Here's where all your education and training come to the test. Usually a patient shows signs he's going to fail, can you notice them? Can you think of what might be needed to help a patient? Can you use your skills to diagnose and come up with ideas to help the doctor help the patient? Can you see the big picture? Do you know how to manage a ventilator? Do you know when a patient can come off a ventilator? This, in my opinion, is the greatest part of the job.

These are the main tasks that we do. What makes it even more interesting and challenging is we have to do this for all age groups, and we work the entire hospital. In this way, you have to keep up on our skills and education. You'll be on your feet a lot. It can be fun too.